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J Thorac Cardiovasc Surg 2007;134:1453-1460
© 2007 The American Association for Thoracic Surgery

Cardiopulmonary Support and Physiology

Insulin treatment enhances the myocardial angiogenic response in diabetes

^a Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
^b Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

Read at the Eighty-seventh Annual Meeting of The American Association for Thoracic Surgery, Washington, DC, May 5-9, 2007.

Received for publication May 8, 2007; revisions received July 24, 2007; accepted for publication August 2, 2007.

^_* Address for reprints: Frank W. Sellke, Beth Israel Deaconess Medical Center, 110 Francis St, LMOB 2A, Boston, MA 02215. (Email: fsellke{at}caregroup.harvard.edu).

Objective: Growth factor and cell-based angiogenesis are attractive therapeutic options for diabetic patients with end-stage coronary disease. Reduced collateral vessel formation observed in diabetes is associated with increased expression of anti-angiogenic proteins, angiostatin and endostatin. The aim of this study was to determine the effects of insulin treatment on the diabetic angiogenic response to chronic myocardial ischemia.

Methods: Yucatan miniswine were treated with alloxan (pancreatic ß-cell specific toxin, 150 mg/kg) and divided into two groups. In the diabetic group (DM, n = 8), blood glucose levels were kept greater than 250 mg/dL, and in the insulin-treated group (IDM, n = 6), intramuscular insulin was administered daily to keep blood glucose less than 150 mg/dL. A third group of age-matched swine served as nondiabetic controls (ND; n = 8). Eight weeks later, all animals underwent circumflex artery ameroid constrictor placement to induce chronic ischemia. Myocardial perfusion was assessed at 3 and 7 weeks after ameroid placement using microspheres. Microvascular function, capillary density, and myocardial expression of anti-angiogenic mediators were evaluated.

Results: Diabetic animals exhibited significant impairments in endothelium-dependent microvessel relaxation to adenosine diphosphate and substance P, which were reversed in insulin-treated animals. Collateral-dependent perfusion in the ischemic circumflex territory, which was profoundly reduced in diabetic animals (–0.18 ± 0.02 vs +0.23 ± 0.07 mL · min^–1 · g^–1; P < .001), improved significantly with insulin treatment (0.12 ± 0.05 mL · min^–1 · g^–1; P < .01). Myocardial expression of anti-angiogenic proteins, angiostatin and endostatin, showing a 4.3- and 3.6-fold increase in diabetic animals respectively (both P < .01 vs ND), was markedly reduced in insulin-treated animals (2.3- and 1.8-fold vs ND; both P < .01).

Conclusions: Insulin treatment successfully reversed diabetic coronary endothelial dysfunction and significantly improved the endogenous angiogenic response. These pro-angiogenic effects may be mediated through downregulation of anti-angiogenic mediators. Insulin therapy appears to be a promising modality to enhance the angiogenic response in diabetic patients.

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Discussion
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